INCIDENT REPORT FORM
Date:
CONFIDENTIAL
____________________ LOS ANGELES UNIFIED SCHOOL DISTRICT ____________________
Time of Call: LOCAL DISTRICT 8 FAX
_______________ OPERATIONS (310) 817-1305
INCIDENT REPORT FORM
NAME/POSITION OF CALLER:
SCHOOL:
LOCATION OF INCIDENT: School phone: _____ EXT:
DATE AND TIME OF INCIDENT/ALLEGATION: _____ ______
1) VICTIM – Name/DOB: GRADE:
Injuries: _ _____
2) VICTIM – Name /DOB: ____ GRADE: ___ _____
Injuries:
DESCRIPTION OF INCIDENT: _
_______________________
SUSPECT(S): _____
SCHOOL ACTION(S) TAKEN:
REPORTED TO/SPOKE TO:
|Office/Unit Contacted |Person Taking Report |
|Local Police Agency | Badge No. |
|School Police – (213) 625-6631 | Badge No. |
|LAPD Child Abuse Unit - (213) 485-4700 | Badge No. |
|District 8 Operations – (310) 354-3413 | |
|Staff Relations – (310) 354-3412 | |
|District Crisis Team – (323) 754-2856 | |
|School Mental Health – (323) 750-5167 | |
|Nursing – (310) 354-3442 | |
|Environ. Health and Safety – (213) 241-3199 | |
|Food Services – (310) 354-3510 | |
|Complex Project Manager | |
|Maintenance & Operations (213) 792-5226 | |
|Sexual Harassment/Gender Equity (213) 241-7682 | |
|Transportation/Main Branch – (310) 515-3132 | |
|Youth Relations – (213) 745-1990 | |
|Neighboring Schools (if applicable) | |
|CSSA Report completed (if applicable) |Date: _________ CSSA#________________ |
OTHER CONTACTS WHEN APPROPRIATE:
FOLLOW-UP ON STUDENT(S)/ STAFF MEMBER(S) CONDITION (if applicable):
ADMINISTRATIVE FOLLOW-THROUGH:
DISTRICT 8 ACTION(S)(if applicable):
HANDLED BY:
(District Administrator) DATE
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